USCDI Export for the Public

Classification Level Sort descending Data Class Data Class Description Data Element Data Element Description Applicable Standards Submitter Name Submitter Organization Submission Date
Level 0 Care Team Members

Information about a person who participates or is expected to participate in the care of a patient.

Proxy Decision Maker

Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable.

Holly Miller, MD MedAllies
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Audiogram

Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide
https://confluence.hl7.org/display/PHWG/Diagnostic+Audiology+Reporting+…
Subset of this implementation guide that = Audiogram is
•Diagnostic audiology tests performed
•Results of the diagnostic evaluation: left ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of the diagnostic evaluation: right ear, including type, severity, and configuration of hearing loss, if a diagnosis is made.
•Results of diagnostic evaluation in the form of audiogram

Troy Kaji Contra Costa Health Services
Level 0 Laboratory

Analysis of clinical specimens to obtain information about the health of a patient.

Accession number

The unique identifier for a single instance of a specimen received by a laboratory and its analysis.

Riki Merrick Association of Public Health Laboratories
Level 0 Cancer Care Radiation Therapy Outcome/Disease Status

Status of the disease treated with radiation therapy at the time of the record.
This is vital information both for clinical care and for public health policy
The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) noted a Delphi process to identify standard values recommended for classification. These were

Under Treatment

No evidence of disease (NED)

Stable Disease

Partial Response

Progressive Disease

Indeterminate (possible pseudo-progression)

Complete Response

Biochemical Recurrence

Primary Recurrence

Local Recurrence

Nodal Recurrence

Distant Recurrence

In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Disease Status can be selected e.g. Biochemical Recurrence, Nodal Recurrence

Charles Mayo University of Michigan
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Visual Acuity

Narrative clinical assessment of the Visual Acuity evaluation.

Please see suggestions from attached Excel document

Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Visual Fields

Narrative clinical assessment of the Visual Fields evaluation.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Holter monitor

Narrative clinical assessment of the Holter monitor results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

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  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Physical Exam

Narrative clinical assessment of the Physical Exam results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Genetic Testing

Narrative clinical assessment of the Genetic Testing results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Health Status Assessments

Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.

Mental Status Evaluation

Narrative clinical assessment of the Mental Status Evaluation.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Neuropsychological Testing

Narrative clinical assessment of the Neuropsychological Testing results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Clinical Notes

Narrative patient data relevant to the context identified by note types.

  •  
  • Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name. 
Psychological Testing

Narrative clinical assessment of the Psychological Testing results.

Please see suggestions from attached Excel document

Melissa Ayres SSA
Level 0 Cancer Care Pathology Molecular Test Result

Score for the molecular test result identified. For example Pathology Molecular Test Name is ProMark, Result could be 30

American Joint Committee on Cancer e.g. AJCC8

Charles Mayo, PhD University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Volume

Name of target volume structure for radiation therapy (e.g. Prostate).

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Target Dose Volume

Identify targets and overall doses treated with the radiation therapy course. This supports systematic reporting what was done for treatment summaries. For example it enables identifying that the prostate received a dose of 7200 cGy. Where the prescription reflects intent, this element reflects what was delivered.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course - Involves Reirradiation

Does the radiation field for the current course overlap with radiation fields from prior courses of therapy?

Elizabeth Covington University of Michigan
Level 0 Cancer Care Radiation Therapy Course Number Of Sessions in Course

Total number of sessions in the treatment course. A session is the period between when the patient enters the treatment room and when they leave it.

Elizabeth Covington University of Michigan
Level 0 Cancer Care Provider Reported Toxicity Value

For each Cancer Patient - Provider Reported Toxicity record the Toxicity Value corresponding to the Toxicity Measure specified indicates the severity of the toxicity using the standardized table. specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) the values in the standardized set are 0,1,2,3,4,5

The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy

Common Terminology Criteria for Adverse Events
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…

Charles Mayo University of Michigan
Level 0 Cancer Care Provider Reported Toxicity Measure

For each Cancer Patient - Provider Reported Toxicity record the Toxicity Measure specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) is used then the Toxicity Measure would correspond to CTCAE Term (e.g. Dry Mouth, or Dry Mouth)

The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy

Common Terminology Criteria for Adverse Events
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…

Charles Mayo University of Michigan
Level 0 Clinical Tests

Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions.

Endoscopy

Narrative clinical assessment of the Endoscopy results.

Please see suggestions from attached Excel document

Melissa Ayres SSA